| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
215 |
214 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
102 |
67 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
110 |
102 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
489 |
474 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
52 |
31 |
$1K |
| D1110 |
Prophylaxis - adult |
177 |
175 |
$1K |
| D1120 |
Prophylaxis - child |
442 |
435 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
603 |
590 |
$862.07 |
| D0120 |
Periodic oral evaluation - established patient |
267 |
266 |
$718.20 |
| D1330 |
|
510 |
496 |
$465.44 |
| D0340 |
|
103 |
101 |
$280.17 |
| D0140 |
Limited oral evaluation - problem focused |
30 |
30 |
$277.11 |
| D0274 |
Bitewings - four radiographic images |
294 |
275 |
$267.50 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
24 |
24 |
$185.80 |
| D0230 |
Intraoral - periapical each additional radiographic image |
151 |
138 |
$171.52 |
| D0220 |
Intraoral - periapical first radiographic image |
274 |
268 |
$129.58 |
| D0272 |
Bitewings - two radiographic images |
91 |
91 |
$120.96 |
| D0350 |
|
102 |
100 |
$0.00 |
| D1351 |
Sealant - per tooth |
109 |
28 |
$0.00 |
| D0470 |
|
52 |
52 |
$0.00 |